2014_1218 (2) C�IBCK ONE: � � r�� � ���� �
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IRRIGATION DOMESTIC FIRELINE
BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NaME oF Pws: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: __ gl�O S C'�n n,�_// R ,
T3e bacl�low preveation assembly detailed below has bun tested aad main� i�n� � nq� �, '�CC
reguladons aad is cerdfied to be opera�ng within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle e Pressur�Vacut�Breaker
^� Double Check Valve ❑ Amiosphere Vacuum Breaker
�r
Maaufact�uer �a �t's' Siu �
Model Ivumber � � � � / Gt � Located At
Serial Ni�ber D��
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R
Doubie Check Valve Assembly
lst Check 2nd Cbecl: Relief Valve Air Inlet Check Valve
Initial Test DC-Closed Closed Ti,�ht l� Opened at Opened at _osid
!Z Ti�t � � Leal:ed o _nsid _osid
1�81� - �_�S�d Z ; �
� Leal;ed ❑ Did not Opea o I,ealced o
�P�
and
Mataials
Used
Test ARtr DC-Closed Closod Tight o Opeaed at ppeaed at �sid
Repair Tighi o _csid _osid
RP sid
The above is cettifiod to be true.
Fitm Name CertiSed Tesce ��'r� ��u1z�r
Firm Address Cert. Testc No. Pl��l/� ?`�Date 2-�
Gauge # ���� �y��
llate last accuracy tested ��"����/y
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy